=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235431628
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOME DOCTORS MANAGEMENT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2010
-----------------------------------------------------
Last Update Date | 11/17/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 611 HUNTER
-----------------------------------------------------
City | LAKE FOREST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60045-4905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-615-2273
-----------------------------------------------------
Fax | 877-335-6195
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 611 HUNTER
-----------------------------------------------------
City | LAKE FOREST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60045-4905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-615-2273
-----------------------------------------------------
Fax | 877-335-6195
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | MR. SRISH P SRIRAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-615-2273
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 036088401
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RC0001X
-----------------------------------------------------
Taxonomy Name | Clinical Cardiac Electrophysiology Physician
-----------------------------------------------------
License Number | 036088401
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 036088401
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 036088401
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------